Research Article Outcome Determinants of Stroke in a...

Research ArticleOutcome Determinants of Stroke in a BrazilianPrimary Stroke Center

Gustavo W. Kuster,1,2,3 Lívia A. Dutra,1,2,4 Israel P. Brasil,1,2 Evelyn P. Pacheco,1,2

Márcio A. C. Arruda,1 Cristiane Volcov,1,2 and Renan B. Domingues1,2,5

1Hospital Paulistano, 01321-001 Sao Paulo, SP, Brazil2Stroke Integrated Program (PIAVEN), Amil Stroke Network, 01321-001 Sao Paulo, SP, Brazil3Department of Neurology, Faculdade de Medicina do ABC, 09060-650 Santo Andre, SP, Brazil4Department of Neurology, Federal University of Sao Paulo (UNIFESP), 04021-001 Sao Paulo, SP, Brazil5Neurosciences Program, Federal University of Minas Gerais (UFMG), 31270-901 Belo Horizonte, MG, Brazil

Correspondence should be addressed to Gustavo W. Kuster; [email protected]

Received 1 November 2014; Accepted 26 November 2014; Published 11 December 2014

Academic Editor: Graeme Hankey

Copyright © 2014 Gustavo W. Kuster et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. Strokemortality in Brazil is one of the highest amongWestern countries.Nonetheless, stroke outcomedeterminants arestill poorly known in this country. In this study we evaluate outcome determinants of stroke in a primary stroke center in Sao Paulo,Brazil. Methods. We evaluated demographic, clinical, and outcome data of patients with ischemic stroke (IS), transient ischemicattack (TIA), and intracerebral hemorrhage (ICH) admitted at “Hospital Paulistano,” Sao Paulo, Brazil. In-hospital mortality andfunctional outcome determinants were assessed. Univariate and binary logistic regression analysis were performed. Results.Threehundred forty-one patients were included in the study, 52.2% being male with 66.8 ± 15.7 years. The stroke type distribution wasIS: 59.2%, TIA: 29.6%, and ICH: 11.1%. ICH was associated with greater severity and poorer functional outcome. The determinantsof poorer functional outcome were higher NIHSS, lower Glasgow score, and lower oxygen saturation level. The most importantmortality determinant was the presence of visual symptoms. Conclusions. The stroke mortality and stroke outcome determinantsfound in the present study do not remarkably differ from studies carried out in developed countries. Stroke prognosis studies arecrucial to better understand the high burden of stroke in Brazil.

1. Introduction

Stroke is the first cause of disability, the second cause ofcognitive impairment, and the third cause of death in theworld [1]. Two-thirds of all stroke deaths occur in low- andmiddle-income countries, including Latin America coun-tries; however, stroke has been poorly studied in these regions[2]. In Brazil, the largest country in the region, stroke is theleading cause of death and disability and the stroke mortalityis one of the highest among Western countries [3, 4].

The causes of the high stroke burden in Brazil remainspeculative. One possibility is that the prevalence of strokeis higher in Brazil than in other regions. Some prevalencestudies were carried in Brazil but the data are not sufficient

to provide an overview of stroke prevalence in Brazil, sincemost of these studies were carried out in specific regionsthat do not necessarily reflect the whole country reality[5]. Other potential explanations rely on medical assistancedeficiencies, mostly driven by socioeconomic inequality. Infact, previous studies showed that the majority of patients areassisted in public hospitals where diagnostic and therapeuticresources are scarce [6–9]. However, the negative impact ofthese discrepancies on stroke outcome in Brazil still requiresconfirmation by large population studies. At this point fewstudies have evaluated stroke outcome [7–10] in Brazil andthe outcome determinants of stroke in Brazil are still poorlyknown.

Hindawi Publishing CorporationStroke Research and TreatmentVolume 2014, Article ID 194768, 6 pageshttp://dx.doi.org/10.1155/2014/194768

2 Stroke Research and Treatment

Several variables including the higher score with NIHStroke Scale (NIHSS), higher age, atrial fibrillation, hyperten-sion, diabetes mellitus, lower level of consciousness, highertime between stroke onset and admission, and the presenceof visual field abnormalities at the first evaluation have beenconsidered predictors of stroke poor outcome [11–16]. Mostof the outcome determinants studies were carried out indeveloped or Asian countries.

The aim of the present study was to evaluate strokeprognosis and stroke prognosis determinants in a populationof stroke patients seen in a primary stroke center in Sao Paulo,the largest Brazilian city.

2. Methods

This study was carried out between 2012 and 2014 at HospitalPaulistano, a Joint Commission International certified strokecenter located in the central region of Sao Paulo, Brazil. Thisstudy protocol was approved by the Ethics Committee onResearch of Hospital Paulistano (Amil Stroke Network) andinformed consent was obtained from each participant or legalrepresentative.

2.1. Patients and Procedures. Patients that presented to theemergency room with suspected stroke were evaluated bya neurologist at admission and submitted to a standardizedprotocol. Demographical data, time delay between strokeonset and admission, stroke warning symptoms (weak-ness and numbness, confusion, speech difficulties, com-prehension problems, vision abnormalities, walking trou-bles, severe headache, dizziness, and incoordination), andstroke risk factors (hypertension, smoking, contraceptiveuse, obesity, familial history, diabetes, previous stroke, ortransient ischemic attack) were compiled. We also collectedthe following data at admission: vital signs, capillary glucose,oxygen saturation levels, Glasgow coma scale score, andNational Institutes of Health Stroke Scale (NIHSS).

After initial evaluation patients were submitted to non-contrast brain CT with 10-mm slice thickness and radio-logical findings (detectable brain infarct, dense artery sign,local intracerebral hemorrhage, distant brain hemorrhage,and cerebral edema) were recorded. Patients were diagnosedas having ischemic stroke (IS), transient ischemic attack(TIA), intracerebral hemorrhage (ICH), or subarachnoidhemorrhage (SHA) according to previously established def-initions [17]. Data of IS treatment including thrombolytictherapy, the use of antithrombotic agents in the first 48 hours,and venous thrombosis prophylaxis were collected. Patientswithout confirmed stroke and patients with SHA were notincluded. The outcome determinants analysis was carriedexclusively in the groups of patients with confirmed IS orICH.

2.2. Statistical Analysis. Statistical analysis was performedusing SPSS version 15.0 forWindows.The confidence intervalwas of 95% and the significance level was set at 𝑃 < 0.05.Normality was assessed using the Kolmogorov-Smirnov test.Student’s 𝑡-test was used for continuous data and categorical

Table 1: Demographical, clinical, and radiological data of the 341patients included in the study.

Characteristics FindingsAge (mean ± SD) 66.8 ± 15.7 yearsGenderMale (%) 52.2Female (%) 47.8

Type of strokeIS (%) 59.2TIA (%) 29.6ICH (%) 11.1

Previous hypertension (%) 68Diabetes (%) 37Previous stroke (%) 26.4Smoking (%) 14Obesity (%) 7.9Familial history of stroke (%) 7Time of symptoms at arrival∗(mean ± SD) 1661 ± 3979 minutes

Wake-up stroke (%)∗ 25.2Stroke warning symptoms∗

Weakness and numbness (%) 66.6Confusion, speech difficulties, andcomprehension problems (%) 39

Dizziness and incoordination (%) 19.6Severe headache (%) 16.7Walking troubles (%) 16.4Vision abnormalities (%) 11.1

Systolic blood pressure (mean ±SD)∗ 148.9 ± 54.1mmHg

Diastolic blood pressure(mean ± SD)∗ 84.1 ± 42.8mmHg

Heart rate (mean ± SD)∗ 80.8 ± 15.9 beats per minuteOxygen saturation level(mean ± SD)∗ 95.9 ± 3%

Capillary glycemia (mean ± SD)∗ 137.1 ± 56.1mg/dLTemperature (mean ± SD)∗ 35.9 ± 2.9 CelsiusGlasgow score (mean ± SD)∗ 14.1 ± 2.3

NIHSS at admission∗ Median = 2, interquartilerange = 5

NIHSS at discharge∗∗ Median = 0, interquartilerange = 2

∗Data obtained at the first evaluation; ∗∗data obtained at discharge; IS:ischemic stroke; ICH: intracerebral hemorrhage; TIA: transient ischemicattack; NIHSS: National Institutes of Health Stroke Scale.

data were compared using Chi-square analyses. In-hospitalmortality and modified Rankin score (mRs) at discharge,whereby the patients were divided into two groups, onewith mRs ≤ 2 and other with mRs > 2, were defined asoutcomes measures. Binary logistic regression analysis was

Stroke Research and Treatment 3

Table 2: Comparison of clinical and radiological data according to the modified Rankin score (mRs) at discharge.

mRs ≤ 2(𝑁 = 157)

mRs > 2(𝑁 = 73) 𝑃 𝑃

∗

Age 65.1 ± 15.5 72.2 ± 15 <0.001 0.398Male 90 (39.1%) 36 (15.7%) 0.256 —Smoking 25 (10.1%) 9 (3.9%) 0.463 —Hypertension 105 (45.7%) 58 (25.2%) 0.061 —Obesity 15 (6.5%) 7 (3%) 0.993 —Family history 12 (5.2%) 4 (1.7%) 0.548 —Diabetes 60 (26.1%) 29 (12.6%) 0.827 —Previous stroke 42 (18.3%) 19 (8.3%) 0.908 —Weakness and numbness 109 (47.4%) 54 (23.5%) 0.307 —Confusion, speech difficulties, and comprehension problems 53 (23%) 38 (16.5%) 0.017 0.130Vision abnormalities 24 (10.4%) 2 (0.9%) 0.012 0.998Walking troubles 22 (9.5%) 18 (7.8%) 0.071 —Severe headache 27 (11.7%) 7 (3%) 0.147 —Dizziness and incoordination 33 (14.3%) 11 (4.8%) 0.239 —CT detectable brain infarct 25 (10.9%) 20 (8.7%) 0.035 0.778CT dense artery sign 3 (1.3%) 7 (3%) 0.073 —Cerebral edema 4 (1.7%) 11 (4.8%) 0.004 1.000Wake-up stroke 35 (15.2%) 26 (11.3%) 0.068 —SBP 147.3 ± 25.8 147.2 ± 29.5 0.973 —DBP 86.8 ± 60.4 84.5 ± 15 0.745 —HR 80.4 ± 15.5 81.8 ± 19.3 0.563 —Sat O2 96.5 ± 2.1 94.4 ± 4.5 <0.001 0.026Temperature 35.9 ± 2.9 35.6 ± 4.4 0.555 —Digital glycemia 130.8 ± 50.1 148.7 ± 62 0.040 0.846Time of symptoms 1359.6 ± 2697 1850.8 ± 4091.4 0.330 —Glasgow (initial) 14.7 ± 1.4 13.1 ± 3.2 <0.001 0.008NIHSS (initial) Median = 1, IR = 3 Median = 12, IR = 14 <0.001 <0.001CT: computed tomography; SBP: systolic blood pressure; DBP: diastolic blood pressure; HR: heart rate; Sat O2: oxygen saturation; NIHSS: National Institutesof Health Stroke Scale; IR = interquartile range; 𝑃: according to 𝑡-test (continuous variables) or Chi-square test (categorical variables); 𝑃∗: according to binarylogistic regression analysis with significant variables.

performed after excluding nonsignificant variables with in-hospital mortality and discharge Rankin modified score asdependent variables.

3. Results

Demographic data, stroke risk factors, stroke warning symp-toms, and clinical data from the 341 patients included in thestudy are shown in Table 1.

The therapeutic measures adopted in patients with brainischemia were as follows: twenty-seven out of the 202 patientswith IS (13.4% of all IS patients) were treated with throm-bolytic treatment, 18 (8.9%) with intravenous and 9 (4.4%)with endovascular therapy. Two hundred fifty-eight out of303 patients with IS and TIA (85.1%) received antithrombotictherapy within 48 hours after stroke and 93.1% of the groupof patients with either IS or TIA received venous thrombosisprophylactic treatment. Among ICH patients, nine (23.7%)

were submitted to surgical treatment and the others receivedconservative treatment.

When comparing the clinical features and outcome ofpatients with IS and ICH, we found that patients with ICHhad a more severe disease than patients with IS. Patients withIS had higher diastolic blood pressure (IS: 82 ± 15.6, ICH:100.9 ± 120, 𝑃 = 0.011), lower oxygen saturation levels (IS:96 ± 2.7, ICH: 94.9 ± 4.5, 𝑃 = 0.038), and lower Glasgowscore at admission (IS: 14.3 ± 1.9, ICH: 12.5 ± 3.8, 𝑃 < 0.001).At discharge patients with ICH had higher NIHSS scores(IS median = 0, interquartile range = 2, ICH median = 2.5,interquartile range = 10, and 𝑃 < 0.001) and higher mRS(IS median = 0, interquartile range = 2, ICH median = 1.5,interquartile range = 4, and 𝑃 < 0.001).

The outcome measures were evaluated in patients with ISand ICH. Twenty-eight out of 315 patients (8.9%) died duringhospitalization, 23 (8.2%) of the patients with IS and 5 (13.9%)of the patients with ICH (𝑃 = 0.256). At hospital discharge


Table 3: Comparison of clinical and radiological data of survivors and patients that died during hospitalization.

Survivors(𝑁 = 287)

In-hospital death(𝑁 = 28) 𝑃 𝑃

∗

Age 66.4 ± 15.8 68.5 ± 16.7 0.509 —Male 156 (49.5%) 15 (4.8%) 0.555 —Smoking 44 (14%) 4 (1.3%) 0.904 —Hypertension 194 (61.6%) 22 (7%) 0.361 —Obesity 23 (7.3%) 4 (12.7%) 0.498 —Family history 20 (6.3%) 2 (0.6%) 0.001 —Diabetes 107 (34%) 9 (2.8%) 0.652 —Previous stroke 75 (23.8%) 9 (2.8%) 0.189 —Weakness and numbness 192 (60.9%) 19 (6%) 0.179 —Confusion, speech difficulties, and comprehension problems 111 (35.2%) 10 (3.2%) 0.121 —Vision abnormalities 27 (8.6%) 7 (2.2%) 0.024 0.018Walking troubles 47 (14.9%) 5 (1.6%) 0.072 —Severe headache 48 (15.2%) 7 (2.2%) 0.135 —Dizziness and incoordination 60 (19%) 5 (15.9%) 0.064 —CT detectable brain infarct 56 (17.8%) 7 (2.2%) 0.538 —CT dense artery sign 13 (4.1%) 3 (0.9%) 0.005 0.599Cerebral edema 18 (5.7%) 2 (0.6%) 0.002 1.000Wake-up stroke 78 (24.8%) 4 (1.3%) 0.282 —SBP 150.2 ± 58 142.1 ± 24.7 0.165 —DBP 84.8 ± 46.2 81.8 ± 15.6 0.463 —HR 80.7 ± 15.8 78.2 ± 19.5 0.516 —Sat O2 95.8 ± 3.2 96.5 ± 2.4 0.180 —Temperature 35.9 ± 3.1 36 ± 0.4 0.460 —Digital glycemia 136.6 ± 55 122 ± 33.9 0.100 —Time of symptoms 1777.7 ± 4215.2 773.25 ± 1180.7 0.009 0.252Glasgow (initial) 5.4 ± 7.5 6 ± 7.6 0.685 0.293NIHSS (initial) Median = 2, IR = 8 Median = 2, IR = 10 0.694 0.125CT: computed tomography; SBP: systolic blood pressure; DBP: diastolic blood pressure; HR: heart rate; Sat O2: oxygen saturation; NIHSS: National Institutesof Health Stroke Scale; IR = interquartile range; 𝑃: according to 𝑡-test (continuous variables) or Chi-square test (categorical variables); 𝑃∗: according to binarylogistic regression analysis with significant variables.

31.7% of the survivors had mRs > 2, 28.1% of the IS patientsand 62.5% of ICH patients (𝑃 < 0.001). Tables 2 and 3 showthe comparisons of characteristics of patients according to theoutcome measures. After binary regression analysis the onlyvariables significantly associated with mRs > 2 at dischargewere ICH diagnosis (𝑃 < 0.001), lower oxygen saturation(𝑃 = 0.026), lower Glasgow score (𝑃 = 0.008), and higherNIHSS at onset (𝑃 < 0.001).The only variable associatedwithin-hospital death was the presence of vision field abnormalityat admission (𝑃 = 0.018).

4. Discussion

To our knowledge this was the first study to evaluate out-come determinants in a Brazilian primary stroke center.We found that lower Glasgow score, lower NIHSS, andlower oxygen saturation were independently associated withpoorer functional outcome and that visual symptoms at onsetwere independently associated with in-hospital mortality.

These findings are in line with previous studies. NIHSS hasbeen demonstrated as one of the most important outcomepredictors among patients with IS [13–16]. Reduced level ofconsciousness and reduced Glasgow score were found to beassociated with poorer outcome in patients with IS [16] andin patients with ICH [18, 19]. Lower oxygen saturation atadmission is inversely correlated with stroke prognosis [20].Visual field abnormalities were associated with unfavorableoutcome in patients with IS in a previous study [16]. Theassociation of visual symptomswith poorer outcome could berelatedwith posterior circulation involvement, explaining theworse outcome. Other variables were previously associatedwith poorer outcome: age, hypertension, diabetes and glucoselevel at admission, CT hyperdense artery sign, and CThypointensity [16, 21, 22]. In our study some variables wereassociated with outcome only by univariate analysis. Patientswith poorer functional outcome were of higher age andhad higher glucose level, more frequent confusion, visionabnormalities, CThypodensity, and cerebral edema; however,

Stroke Research and Treatment 5

these differences were not significant after adjusted analysis.CT dense artery sign and cerebral edema were more frequentamong those who died during hospitalization; however,these differences were no longer significant after regressionanalysis. It is possible that the small sample size in the presentstudy did not allow the demonstration of other significantdifferences.

The mean stroke age we found was similar to what wasfound in a recent study in United States [23]. ICH proportionand ICH severity were similar to previous descriptions [24].The therapeutic measures registered here are in accordancewith stroke care quality indicators. The percentage of ISpatients treated with tPA in our study was even higher thanin previous population studies [25], probably reflecting thefact that our study was carried in a single institution with 24-hour neurologist and a stroke protocol. The rate of patientsthat received antithrombotic therapy within the first 48hours after stroke (85.1%) and the rate of patients submittedto venous thrombosis prophylactic treatment (93.1%) aresimilar to what was previously reported in US hospitals[26, 27] and in other private hospitals in Brazil [28]. Thein-hospital mortality rate registered here was not discrepantfrom previous studies in developed countries [29]. Overallthese data suggest that the clinical, therapeutic, and outcomecharacteristics of the population of the present study donot remarkably differ from stroke populations in developedcountries. It is likely that this reflects the fact that the presentstudy was carried out in a private institution, with avail-ability of all stroke validated therapies. Our hospital servespredominantly middle and upper middle class patients. Theemergence service of our hospital has a neurologist 24 hoursa day, 7 days a week, a nurse in charge of the management ofstroke cases, intensive care unit, 24-hour CT scan, magneticresonance imaging, and an interventional neuroradiologyservice available 24 hours a day, 7 days a week. It is a primarystroke center certified by Joint Commission International thatfollows the American Heart Association guidelines. Consid-ering the specificities of our service, large and multicentricstudies are still needed to determine if the outcome of strokeamong patients assisted in public Brazilian hospitals differsfrom private hospitals.

Our study has some limitations that deserve to bementioned. We analyzed a small and a single center sample.Our results need confirmation in larger and multicentricstudies involving different Brazilian regions with differentsocioeconomic levels. Another limitation is that this studydid not include follow-up of the patients and we evaluatedonly in-hospital outcomes, while most of the prognosticstudies assess three-month outcome. Future outcome studiesshould address long-term outcome in patients with strokein Brazil. As strengths of this study the population washomogeneous and the same stroke team assisted all thepatients following the same stroke protocols.

In conclusion, the present study was the first to specif-ically assess outcome determinants in a Brazilian primarystroke center with availability of all current validated stroketherapies. The outcome and outcome determinants reportedin the present study shared great similarities with previousstudies in developed countries. Population studies are still

necessary to better understand the great burden of stroke inBrazil.

Disclosure

Dr. Renan B. Domingues is a recipient of a CAPESDomingues is a recipient of a CAPES postdoctoral scholar-ship.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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